Standard Operational Procedure 1 (SOP 1) Mixed Sex Accommodation Why we have a procedure? This SOP is required to ensure adherence to the NHS England Delivering Same Sex Accommodation Guidance to ensure there is no mixed sex breach on the wards at BCPFT. Every patient has the right to receive high quality care that is safe, effective and respects their privacy and dignity. Responsibility for these rights does not lie with one individual or group, but with all staff at all levels. What overarching policy the procedure links to? NHS England Delivering Same Sex Accommodation, Guidance for Providers and Commissioners. It is also linked to the Safeguarding Adults at Risk Policy. Which services of the trust does this apply to? Where is it in operation? Division Inpatients Community Locations Mental Health Services Learning Disabilities Services Children and Young People Services Penn Hospital, Edward Street Hospital and Hallam Street Hospital Who does the procedure apply to? All staff within the inpatient units and on-call managers, directors and medics. When should the procedure be applied? This SOP relates to sudden deterioration and infection control situations and emergency admissions both in and out of hours. Any transgender patients that are admitted, staff should refer to the Good Practice Guide for Support Transgender Clients. All admissions and transfers to be included. How to carry out this procedure: Same sex accommodation is defined as sleeping accommodation, toilet and/or washing facilities which patients share only with people of the same sex. A breach is defined as occurring when males and females are required to: Share sleeping accommodation the patient is admitted to a bed space that is within a bay with members of the opposite sex Share toilets, shower/washrooms or bathrooms Mixed Sex Accommodation SOP Page 1 of 5 Version 1.0 August 2018
Pass through an area of opposite sex accommodation to access toilets, shower/washrooms, bathrooms or their own sleeping accommodation Patients should not have to share mixed toilet and shower/washing facilities with people of the opposite sex. Patients should not have to pass directly through opposite sex areas to reach their own facilities. Toilet and washing facilities must be designated by gender using provider approved signage. It is the responsibility of the nurse in charge to check that facilities are correctly signed following bay moves and re-checked as a minimum once per shift. A bay is a single or multi-bedded sleeping area which is fully enclosed on three sides with solid walls. The use of curtains alone between bays does not constitute single sex. Meadow Ward at Penn Hospital has a swing bed facility which can be used for either male or female clients, patients must be of the same sex when it is used. Salter 2 bedded bays, which is situated near to the entrance and is between the male and female corridors, can be switched to accommodate two male or female beds without breaching the mixed sex accommodation, the bay has got its own toilet facility. Hallam Street: all male patients or visitors must be escorted by a member of staff through the female side to access the multipurpose room where ward reviews are held. Doors between the female and male side of the wards are always to remain locked and the garden continues to have a physical divide. Swing Bed: Swing bed facility is situated in between the of Male and female bedroom area, there are two bed rooms within that space and can be locked on either side in order to be able to use it for either Male Swing beds or Female swing beds. Swing bed facility allows us to change the allocation of 2 beds for male or female as required, the swing has to have 2 people of the same sex admitted at one time; i.e if one bed is occupied by the female patient the second bed cannot be used for Male patient. Sudden Deterioration of Patient or Infection Control (in hours): Nurse in charge to call an MDT meeting Involve the ward management to identify the right bed Contact another ward to see if they have an appropriate bed available Consider the use of leave beds Review patients to see if anyone is well enough to go on leave to create a bed Inform the Matron and Service Manager to look at the possible options Consider swapping wards around (Female and Male area) Inform General Manager and Head of Nursing of issue Contact out of area Trusts to see if they have a vacant male/female bed available Mixed Sex Accommodation SOP Page 2 of 5 Version 1.0 August 2018
Sudden Deterioration of Patient or Infection Control (out of hours): Nurse in charge to call on call manager Nurse in charge to call Duty Senior Nurse who will call on call manager (Penn Hospital) Check if there is another bed available on another ward If a bed is not available in the appropriate gender area, a leave bed in the appropriate area is to be considered if it is available If advice given does not resolve issue, call Consultant on call. If issue still not resolved escalate to Director on call. Admission of Patients (in hours): Bed manager to liaise with ward manager to identify if bed available Admission to the correct patient gender (male/female) area if bed is available If no bed is available, review the use of leave beds as required Look at alternative wards Inform the Matron and Service Manager to look at the possible options Consider swapping wards around (Female and Male area) Look at out of area beds Admission of Patients (out of hours): Clinical need must be considered for each individual patient, if a patient is admitted into a bay, then all patients must be same sex. Referrer to discuss admission with Nurse in charge Admission to the correct patient gender (male/female) area if bed is available If no bed is available, Nurse in charge to call on call manager Nurse in charge to call Duty Senior Nurse who will call on call manager (Penn Hospital) If no bed is viable, review the use of leave beds as required If no bed available look at alternative wards If no bed available in BCPFT, referrer to look at out of area beds Reporting of Breaches: Input onto Datix Assurance Report Ward Management Ward Manager to escalate the Matron and Service Manager Inform General Manager and Head of Nursing of issue Where do I go for further advice or information? Ward Managers Service Manager/ Matron On call Manager General Manager/ Head of Nursing Mixed Sex Accommodation SOP Page 3 of 5 Version 1.0 August 2018
Director on call Consultant on call Training Where it is identified in their appraisal as part of the specific development needs for their role and responsibilities. Please refer to the Trust s Mandatory & Risk Management Training Needs Analysis for further details on training requirements, target audiences and update frequencies Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness. Equality Impact Assessment Please refer to overarching policy Data Protection Act and Freedom of Information Act Please refer to overarching policy Mixed Sex Accommodation SOP Page 4 of 5 Version 1.0 August 2018
Standard Operating Procedure Details Unique Identifier for this SOP is State if SOP is New or Revised BCPFT-SAFE-SOP-02-1 New Policy Category Executive Director whose portfolio this SOP comes under Policy Lead/Author Job titles only Committee/Group Responsible for Approval of this SOP Month/year consultation process completed Safeguarding Executive Director of Nursing, AHPs and Governance Service Manager/PMO Mental Health Quality and Safety Committee September 2018 Month/year SOP was approved September 2018 Next review due August 2021 Disclosure Status B can be disclosed to patients and the public Review and Amendment History Version Date Description of Change 1.0 Aug 2018 New SOP for BCPFT to support the Safeguarding Adult at Risk Policy and the NHS England Delivering Same Sex Accommodation, Guidance for Providers and Commissioners. Mixed Sex Accommodation SOP Page 5 of 5 Version 1.0 August 2018